Question:
why are so few doctors doing the bpd/ds?

I have read such glowing reports from people who have had BPD/DS who make it sound as though this is the perfect cure for morbid obesity. Why then are there such a limited number of surgeons performing it? Is there some problem with this surgery that I am not hearing?    — Nikki (. (posted on November 22, 2000)

November 22, 2000
People who choose the BPD/DS are generally satisfied with the surgery just as people who are fully informed and choose the RNY instead of other procedures are. :) I wouldn't really say it is a 'superior' surgery overall because it is NOT for everyone and it does require daily supplementation, regular medical follow ups, etc. However, the BPD/DS does incorporate a few innovations that other existing WLS surgeries do not: The stomach is made smaller, but retains full functionality as pre-operatively. The malapsorption occurs because the small intestines are transformed into two separate limbs: one carries the 'chyme' that the stomach has fully processed and the other carries the bile/pancreatic juices needed for digestion. Since these two don't meet until the last 100 cms of small intestines, a certain percentage of nutrients are not absorbed. One has to take nutritional supplements but should not face serious deficiencies if they take supplements and get proper aftercare. The malapsorption causes a greater percentage of weight loss overall and also contributes to maintenance of ideal weight long term. So, even though special care must be taken post-operatively, the malapsorption is a key factor for 'permanant' weight loss and maintenance. Of course, it ISN'T a magic bullet: One's nutritional choices, level of activity/exercise greatly influence metabolism and weight loss/maintenance as well. However, the surgery does have a built-in component which can *help* the weight stay off. BEing that is a relatively 'new' procedure, many surgeons confuse it with an earlier surgery, the BPD, which has been generally noted to result in serious nutritional deficiences for many patients (although not all since there are very healthy BPD patients living out there!). THis negative bias is one reason why the BPD/DS isn't a commonly performed procedure. ANother reason is the surgery's complexity: There undoubtedly is a great learning curve for surgeons if they are to incorporate it into their practice. Not only does it involve partial removal of the stomach but also total reorganization of the small intestines. It is not a 'bypass' per se: The intestines are totally utilized -- one limb carries food and the other carries bile/pancreatic juices. It's not like a section is just bypassed and sewn to another area of the intestines. There have been long term (15 year) studies done on the BPD/DS (see Hess's report at www.duodenalswitch.com). To date, there have NOT been any problems reported with the surgery. In fact, the surgeries benefits have been outlined and documented. I think that the BPD/DS as a standard WLS will occur as more surgeons become educated/trained and more people become informed about it. Unfortunately, there are still many websites that carry totally inaccurate information (citing results from the BPD, which don't apply to the BPD/DS or do not even mention the BPD/DS alltogether!). There are probably many doctors who also do not have a full understanding of the surgery, thinking that it is the BPD when it is not. The BPD/DS incorporates adjustments/improvements to the BPD: The malapsorption effect is lessened by allowing a portion of the duodenum (the first section of the small intestines) to remain intact before splitting the remainder of the intestines into two sections: One, the alimentary limb, carries food. The other carries bile/pancreatic juices. The common tract, where food is actually processed in the area before the colon, has been lengethened to a standard of 100 cm instead of the previous 50 cms. The surgery now involves patient knowledge and understanding about necessary nutritional supplementation and importance of protein consumption, etc. REgular aftercare can detect any nutritional deficiencies BEFORE they become so serious as to require parental feedings, etc. This lack of patient information was a major factor in the development of nutritional deficiencies in long term post-op BPD patients. The BPD/DS is different from the BPD (and RNY) in another radical way: The stomach is cut lengthwise (a sleeve gastrectomy), thus leaving the pylorus intact (this did NOT occur with the BPD). The stomach is made smaller because a large portion of the acid producing and storage fundus is removed, but it retains full functionality and shape. This is one of the main advantages over all other WLS surgeries for me. All other surgeries (RNY, distal RNY, BPD) requires the creation of a small 'pouch' with the upper part of the stomach and bypasses the lower stomach/pylorus (or removing it as with the BPD). The reason so few surgeons before BPD/DS is not because there are problems with the surgery. It is a newer and more complex surgery that, at this point, has not yet become standard practice in the WLS community. Many are very conservative towards it since it is a newer procedure. The complexity of the surgery is a reason why so few surgeons actually peform it laparoscopically as well.
   — Teresa N.

November 22, 2000
Teresa gave an excellent perspective. However, here is probably the most accurate reason: A surgeon can perform 3-4 RNY procedures in the same time it takes to do 1-2 LGR/DS procedures, for which they receive the same compensation per procedure. Now a doc will never say he is motivated by profit to a patient, but I know the behind the scenes conversations. They have to make a living too.
   — merri B.

November 23, 2000
MERRI: There you go -- the bold economics of it all! LOL This is probably a factor as well. But, I think that the more patients become aware of this possibility and demand/inquire about it, the more surgeons will try to integrate it into their surgical offerings. I don't know if they'll really wholeheartedly want the majority of patients to get it because it is more complex, takes more time, etc. It also involves a lot of post-op follow up care on the surgeon's part. :) All the best,
   — Teresa N.

November 24, 2000
I think Mary hit the nail on the head... Also, the DS is the newest in evolutions of WLS. To read about the history of Weight Loss Surgery go to: <a href="http://www.surgery.usc.edu/divisions/cr/obesity.html">History of WLS</a>. There are more & more surgeons doing the DS all the time. When I had surgery in Oct of 1999, I had a choice of 12 surgeons world wide. In a years time, there are now closer to 40 surgeons doing this surgery & revising other surgeries to the DS. It's definately a growing field! Good luck with your research...
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